Provider Demographics
NPI:1902000763
Name:BIG PARK FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:BIG PARK FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:928-300-4783
Mailing Address - Street 1:PO BOX 21540
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86341-1540
Mailing Address - Country:US
Mailing Address - Phone:928-300-4783
Mailing Address - Fax:928-634-0337
Practice Address - Street 1:61 BELL ROCK PLZ
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-8810
Practice Address - Country:US
Practice Address - Phone:928-300-4783
Practice Address - Fax:928-634-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ115794Medicare PIN